What is the next best step in managing a patient with suspected right-sided stroke and normal point-of-care (POC) glucose?

Immediate Brain Imaging is the Next Best Step for Suspected Right-Sided Stroke with Normal POC Glucose

For a patient with suspected right-sided stroke and normal point-of-care glucose, the next best step is to obtain an urgent non-contrast CT scan of the brain to differentiate between ischemic and hemorrhagic stroke. 1, 2

Rationale for Immediate Brain Imaging

Brain imaging is critical for several reasons:

1. Differentiation between stroke types: CT scan distinguishes between ischemic and hemorrhagic stroke, which require completely different management approaches 1

2. Time-sensitive treatment decisions: Imaging results determine eligibility for reperfusion therapies like intravenous thrombolysis (rtPA) or mechanical thrombectomy 1

3. Ruling out stroke mimics: Several conditions can present with stroke-like symptoms but require different management 2

4. Establishing baseline: Initial imaging provides a reference point if neurological status changes 1

Diagnostic Pathway After Normal Glucose

Since hypoglycemia (a common stroke mimic) has been ruled out with the normal POC glucose, the diagnostic algorithm proceeds as follows:

1. Immediate brain CT: Should be completed within 25 minutes of arrival 1, 2

   • Non-contrast CT is the first-line imaging modality
   • Should be performed urgently (within 24 hours, but ideally ASAP) 1

2. Concurrent actions while awaiting CT results:

   • Obtain baseline vital signs and neurological assessment using NIHSS 1
   • Establish IV access for potential thrombolysis 1
   • Order basic laboratory tests (CBC, coagulation studies, electrolytes, renal function) 1
   • Obtain 12-lead ECG to identify potential cardiac causes 1

3. After CT results:

   • If ischemic stroke: Evaluate eligibility for thrombolysis or endovascular therapy
   • If hemorrhagic stroke: Consult neurosurgery and manage blood pressure accordingly
   • If normal CT but high clinical suspicion: Consider MRI with diffusion-weighted imaging 3

Important Considerations

• Time is brain: Every minute delay in treatment increases morbidity and mortality 1
• Door-to-CT time target: Less than 25 minutes from hospital arrival 4, 5
• Direct-to-CT protocols: Taking patients directly from EMS to CT can reduce door-to-imaging times by 3-10 minutes 4, 5

Common Pitfalls to Avoid

1. Delaying imaging for additional tests: Do not wait for complete laboratory results before obtaining brain imaging 2
2. Overlooking posterior circulation strokes: Right-sided symptoms may represent posterior circulation involvement, which can be more difficult to detect on CT 3
3. Misinterpreting early CT findings: Early ischemic changes can be subtle and require experienced interpretation 3
4. Failing to monitor vital signs: Continue to monitor neurological status, oxygen saturation, and blood pressure while awaiting imaging 1

By following this approach, you ensure the most time-efficient pathway to diagnosis and appropriate treatment for a patient with suspected stroke, optimizing chances for good neurological outcomes.